Patient Authorization and Responsibility Form
Patient Name: ___________________________ Date of Birth: ___________________
I, the undersigned, hereby acknowledge and agree to the following terms and conditions:
Authorization/Assignment of Benefits:
I hereby authorize and assign payment of any benefits due me under the terms of any insurance policy or policies that may cover the procedure performed on me, or my dependent(s) by Orthopaedic Medical Group and Athletic Rehabilitation Center, Inc., (hereinafter referred to as OMG) directly to OMG at the address designated by OMG on any claim form submitted to my insurance carrier, _________________________________.
I agree that payment to OMG pursuant to this authorization/assignment by my insurance company shall discharge said insurance company of any and all obligations under the policy to the extent of such payment. I understand and agree that I am financially responsible for charges not covered by this authorization/assignment and I authorize OMG to contact my employer for the purpose of determining the existence and extent of any insurance benefits.
Financial Responsibility:
I understand that my insurance company is being billed as a courtesy and I agree that I am financially responsible to pay for any charges .not covered by my insurance company. Should my account become delinquent, I agree to pay interest on the outstanding balance owed at the maximum amount permitted by law. If OMG undertakes collection eforts to recover any past due amounts, I agree to pay all reasonable costs incurred, including attorney's fees.
Authorization to Release Information to OMG:
I hereby authorize any insurance company, employer, hospital, physician, or utilization review representative to release to OMG any and all information with respect to me or my dependents) which may have bearing on any benefits payable by my insurance company for the procedure performed by OMG on me or my dependent(s). I agree that this authorization shall remain effective for one (1) year from the date indicated below.
Designation of Authorized Appeal Representative:
I hereby designate OMG and/or their authorized agents as my authorized representative to pursue my appeal rights.
_______________________________
Patient Signature or Legal Representative
_______________________________
Print Name
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Date
Orthopaedic Medical Group and Athletic Rehabilitation Center, Inc.
1050 Lakes Drive
Suite 100
West Covina, CA 91790
Tel: 626.918.6655
Fax: 626.918.6633
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